Risk Management



Hotline Question – Amending Records

Q: My patient asked me to amend his record. I feel it is accurate. What do I do? 

A: Patients have a right to access their records and to ask you to amend it. You may decline the request only if:

  • You may exclude the information from access by the individual (e.g., psychotherapy notes)
  • You did not create the information (unless the individual provides a reasonable basis to believe the originator is no longer available)
  • You determine that the information is accurate and complete
  • You do not hold the information in your designated record set.
  • Even if you do not grant the request, you must document the request and explain the reason for your decision to the patient.

For an example of a sample policy with sample forms, see http://policies.usc.edu/hipaa/pat602041403.pdf.

 
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